Rehabilitation Trajectories and Outcomes in Individuals With Mild Traumatic Brain Injury and Psychiatric Histories: A TRACK-TBI Pilot Study

Severe Traumatic Brain Injury Outcomes in Patients with Premorbid Psychiatric Illness

OBJECTIVE

Individuals with psychiatric illnesses (PIs) have increased rates of traumatic brain injury (TBI). Nonetheless, the influence of underlying PI on TBI outcomes is poorly understood.

METHODS

We analyzed the medical records of 633 adult-severe TBI patients admitted to our institution between 2010 and 2021. We identified patients with premorbid PI (Psych (+) group, n = 129) and a subset with only a substance use disorder (SUD (+) group, n = 60) and compared them to patients without PI (Psych (-) group, n = 480). Outcome measures included discharge Glasgow Coma Scale (GCS), length of stay, in-hospital survival, and Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

The Psych (+) group had increased in-hospital survival (69.8% vs. 55.0%, P = 0.003) and fewer patients with severe (3-8) discharge-GCS (28.7% vs. 46.0%, P < 0.001). The SUD (+) group had increased in-hospital survival (70.0% vs. 55.0%, P = 0.028) and fewer patients with severe discharge-GCS (28.3% vs. 46.0%, P = 0.009). However, the Psych (+) (21.0 vs. 10.0 days, P < 0.001) and SUD (+) (16.0 v. 10.0 days, P = 0.011) groups had longer length of stay. The Psych (+) group had a higher mean GOS-E at discharge (2.7 vs. 2.4, P = 0.004), 6-months (3.8 vs. 3.0, P = 0.006) and 1-year (3.4 vs. 2.3, P = 0.027). The SUD (+) group also had a higher mean GOS-E at discharge (2.8 vs. 2.4, P = 0.034), six months (3.8 vs. 3.0, P = 0.035), and one year (3.5 vs. 2.3, P = 0.008). Additionally, there were no significant differences in injury severity or computed tomography scan findings.

CONCLUSIONS

Individuals with PI and SUD appeared to have better outcomes but more complicated hospital stays following severe TBI. Future studies should investigate the mechanisms underlying these outcomes.

Pre-injury psychiatric history, subacute symptoms and personality traits predict social reintegration at 3-month post-mild traumatic brain injury

BACKGROUND

The purpose of the study was to identify whether the presence of a pre-injury psychiatric history, subacute post-concussive symptoms (PCS) and personality traits were predictive of less favorable social reintegration for 3 months following a mild traumatic brain injury (mTBI).

METHOD

A total of 76 patients with mTBI were included, and the presence of a pre-injury psychiatric history was identified from the medical chart. One-month post-accident, these patients completed the Millon Multiaxial Clinical Inventory, 3rd Edition assessing personality traits and the Rivermead Post-Concussion Symptoms Questionnaire to measure subacute PCS. Social reintegration was measured using the Mayo-Portland Adaptability Inventory, 4th Edition at 3-month post-accident.

RESULTS

The presence of pre-injury psychiatric history, high levels of subacute PCS and Cluster B personality traits such as histrionic and borderline features were significant predictors of social reintegration quality at 3-month post injury.

CONCLUSION

This study provides new insights on cluster B personality traits and its influence on recovery and social reintegration at 3-month post mTBI.

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study

BACKGROUND

Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion.

METHODS

Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined.

RESULTS

In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history.

CONCLUSIONS

There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review

BACKGROUND AND PURPOSE

Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI.

METHODS

A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science.

RESULTS

Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited.

CONCLUSIONS

Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.

Rehabilitation for Impaired Attention in the Acute and Post-Acute Phase After Traumatic Brain Injury: A Narrative Review

Impaired attention is the most common and debilitating cognitive deficit following a traumatic brain injury (TBI). Attention is a fundamental function that profoundly influences the performance of other cognitive components such as memory and execution. Intriguingly, attention can be improved through cognitive rehabilitation. This narrative review summarizes the essential elements of rehabilitation for attention problems in acute and post-acute TBI. In the acute phase of mild TBI, investigations into the medical history and daily life performance, neurological examination, screening and management of concomitant sleep-wake disorders or neuropsychiatric disorders, and support and education on the natural course of concussion are covered. Rehabilitation for patients with moderate-to-severe TBI consists of serial assessment for patients with disorders of consciousness and a post-traumatic confusion state. In the post-acute phase after TBI, components of rehabilitation include investigating medical history; neurological, imaging, and electrophysiological tests; evaluation and treatment of factors that may impact attention, including sleep-wake, emotional, and behavioral disorders; evaluation of attention function; and cognitive rehabilitation as a matter of course. We summarized metacognitive strategy, direct attention training, computer-based cognitive interventions, medication, and environmental control as interventions to enhance attention.

Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area through a Global Neurosurgery Paradigm

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persist in the NYMA as well as in low- and middle-income countries (LMIC). Examples include: (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic post-injury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country (HIC) settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

Investigating the Effect of Fatigue and Psychological Distress on Information Processing Speed in the Postacute Period After Mild Traumatic Brain Injury in Premorbidly Healthy Adults

Impairments in processing speed under conditions of increasing cognitive load have been reported in individuals with mild traumatic brain injury (mTBI). In other conditions that are also associated with white matter disruption, both psychological distress and fatigue have been shown to underlie this impairment.

OBJECTIVE

the current study aimed to investigate whether slowing of processing abilities under conditions of greater cognitive load is independent of fatigue and psychological status in premorbidly healthy individuals with subacute mTBI.

METHOD

using a prospective observational design, we examined 84 individuals with mTBI approximately 8 weeks after injury and 47 healthy control (HC) participants. They were assessed with the Symbol Digit Modality Test, an n-back task and a rate of gain of information choice reaction time task that conforms to Hick's law. Participants were also assessed with measures of fatigue and psychological status.

RESULTS

as expected, findings revealed no group differences on simple reaction time tasks, but as task complexity increased, the mTBI group performed more slowly than the HC group. This group difference occurred independently of fatigue and psychological distress levels and was associated with a moderate effect size.

CONCLUSIONS

during the subacute period after mTBI, premorbidly healthy individuals demonstrate impairment in their ability to rapidly process information as the cognitive load of the task increases beyond simple reaction time requirements. Examination of whether these changes affect resumption of premorbid roles is warranted.

Development and description of SAAM intervention: A brief, multidimensional and psycho-educational intervention for adults with mild traumatic brain injury

BACKGROUND

Mild traumatic brain injury (mTBI) is associated with persistent post-concussive symptoms (PCSs) in approximately 15% of cases. These symptoms can be somatic (e.g., headache), cognitive (e.g., forgetfulness, poor attention and concentration capacities), emotional (e.g., anxiety, depression, irritability) and/or sleep-arousal complaints (e.g., fatigue, sleep problems). Although practice guidelines recommend early intervention to prevent and treat PCS, we still lack an effective, standardized, integrative, post-acute intervention based on a sound and validated theoretical model.

OBJECTIVES

The purpose of this article is to present the development and theoretical background underpinning a novel intervention for patients with PCSs in the post-acute phase after mTBI (1-3 months post-injury).

PROCEDURE

With a biopsychosocial approach (Hou et al., 2012) and best practice recommendations, we developed a novel multidimensional intervention targeting factors that perpetuate PCSs and that can be changed with the intervention. This individual-session intervention provides practical tools for managing PCSs and is designed to provide psycho-education and reassurance, reinforce individual objectives and promote a return to activities. Each session targets one category of PCSs: Sleep/fatigue, Attention, Anxiety/depressed mood, Memory/Organization (SAAM intervention). The rationale underlying the choices of format and content for the intervention is discussed, as are the associated strengths, limitations, opportunities and challenges.

CONCLUSION

This article could support researchers and clinicians to develop, replicate and/or implement interventions addressing current best practices in mTBI management.

Blast-Related Traumatic Brain Injury: Current Concepts and Research Considerations

Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as military combat or collision sports. But the wide variability in eliciting circumstances and injury severities makes the study of TBI as a uniform disease state impossible. Military Service members are under additional, unique threats such as exposure to explosive blast and its unique effects on the body. This review is aimed toward TBI researchers, as it covers important concepts and considerations for studying blast-induced head trauma. These include the comparability of blast-induced head trauma to other mechanisms of TBI, whether blast overpressure induces measureable biomarkers, and whether a biodosimeter can link blast exposure to health outcomes, using acute radiation exposure as a corollary. This examination is contextualized by the understanding of concussive events and their psychological effects throughout the past century's wars, as well as the variables that predict sustaining a TBI and those that precipitate or exacerbate psychological conditions. Disclaimer: The views expressed in this article are solely the views of the authors and not those of the Department of Defense Blast Injury Research Coordinating Office, US Army Medical Research and Development Command, US Army Futures Command, US Army, or the Department of Defense.

Chronic Cognitive Deficits and Associated Histopathology Following Closed-Head Concussive Injury in Rats

Close-head concussive injury, as one of the most common forms of traumatic brain injury (TBI), has been shown to induce cognitive deficits that are long lasting. A concussive impact model was previously established in our lab that produces clinically relevant signs of concussion and induced acute pathological changes in rats. To evaluate the long-term effects of repeated concussions in this model, we utilized a comprehensive Morris water maze (MWM) paradigm for cognitive assessments at 1 and 6 months following repeated concussive impacts in rats. As such, adult Sprague-Dawley rats received either anesthesia (sham) or repeated concussive impacts (4 consecutive impacts at 1 h interval). At 1 month post-injury, results of the spatial learning task showed that the average latencies to locate the hidden "escape" platform were significantly longer in the injured rats over the last 2 days of the MWM testing compared to sham controls (p < 0.05). In the memory retention task, rats subjected to repeated concussive impacts also spent significantly less time in the platform zone searching for the missing platform during the probe trial (p < 0.05). On the working memory task, the injured rats showed a trend toward worse performance, but this failed to reach statistical significance compared to sham controls (p = 0.07). At 6 months post-injury, no differences were detected between the injured group and sham controls in either the spatial learning or probe trials. However, rats with repeated concussive impacts exhibited significantly worsened working memory performance compared to sham controls (p < 0.05). In addition, histopathological assessments for axonal neurodegeneration using silver stain showed that repeated concussive impacts induced significantly more axonal degeneration in the corpus callosum compared to sham controls (p < 0.05) at 1 month post-injury, whereas such difference was not observed at 6 months post-injury. Overall, the results show that repeated concussive impacts in our model produced significant cognitive deficits in both spatial learning abilities and in working memory abilities in a time-dependent fashion that may be indicative of progressive pathology and warrant further investigation.